Post on 12-Oct-2020
State of the art:
femtosecond laser cataract surgery
Moschou Konstantinos M.D.
Diathlasis Day Care Unit
13th Ophthalmology Congress of ΟΕΤΗΑΜΒΑ
July 9-10, 2016
Samothraki Village Hotel
Samothraki, Greece
I HAVE NO FINANCIAL INTEREST
Diathlasis Day Care Unit, Thessaloniki, Greece
History of Cataract
The history of cataract surgery dates back to at least 800 BC when
Sushruta in India described the technique
It took more than 2500 years for Jaques Daviel of France to invent ECCE in
1747
200 years later (1950) Sir Harold Ridley implanted the first posterior
chamber IOL
27 years later (1967) Charles Kelman introduced phacoemulsification
Today phacoemulsification is the gold standard of cataract surgery
Its rise was made possible by the invention of capsulorhexis, the use of
foldable IOLs, the use of viscoelastics
Diathlasis Day Care Unit, Thessaloniki, Greece
History of Cataract
Now, 40 years later a new way of lens replacement surgery has arrived:
Laser Refractive Lens Surgery with a Femtosecond Laser
Prof. Zoltan Nagy performed the fist Laser Refractive Lens Surgery with
a Femtosecond Laser in 2008 (LenSx – ALCON)
Diathlasis Day Care Unit, Thessaloniki, Greece
What is a Femtosecond Laser?
1053 nm Neodymium
A laser that emits optical pulses with a duration in the range of
femtosecond (1fs = 10-15 seconds)
This feature allows the light to be focused at a 3μm spot size, accurate
within 5μm in the anterior segment.
Allows for precise cutting of tissue with minimal collateral damage
In ophthalmology surgery since 2001
First FDA approved for LASIK flaps in 2001 and 2010 for cataract
surgery
Diathlasis Day Care Unit, Thessaloniki, Greece
Commercially Available Systems
Z8 (Ziemer)
Alcon LenSx
LensAR
Catalys Optimedica
Victus B+L
Diathlasis Day Care Unit, Thessaloniki, Greece
Diathlasis Day Care Unit, Thessaloniki, Greece
Femtolaser Catalys LenSx Lensar Victus Femto LDV Z8
FDA approvals
corneal + arcuate incisions
Ant. Capsulotomy lens fragmentation
corneal + arcuate incisions
Ant. Capsulotomy lens fragmentation
corneal + arcuate incisions
Ant. Capsulotomy lens fragmentation
corneal + arcuate incisions
Ant. Capsulotomy Corneal flap
is not cleared in the United
States
CE mark Same as FDA Same as FDA Same as FDA
corneal + arcuate incisions
Ant. Capsulotomy lens fragmentation
is not cleared in in all other countries
Commercially Available Systems
Commercially Available Systems
With guidance systems OCT or Scheimpflug
technology it is used to make:
Capsulorhexis
Clear corneal incisions
Arcuate incisions
Lens Fragmentation
Diathlasis Day Care Unit, Thessaloniki, Greece
Reproducible size, shape and well-centered
Too large Too small Irregular shape Off center
No capsule-IOL overlap
IOL tilt
Phimosis
Difficult phaco maneuver
IOL tilt
IOL decentration
IOL decentration
Edge catches visual axis
Ideal Capsulorhexis
Diathlasis Day Care Unit, Thessaloniki, Greece
Femtosecond Laser Capsulorhexis
Reproducible, Precise Circular Shape and Diameter Capsulotomy
Enables Image-Guided Centration of Capsulotomy
Diathlasis Day Care Unit, Thessaloniki, Greece
Manual Surgery Femtocat. Surgery
Manual vs. Femtocataract Surgery 1 month postop
Diathlasis Day Care Unit, Thessaloniki, Greece
Does Capsulotomy Size Impact ELPo?
Consistent capsulorhexis diameter is critical to Effective Lens Position1,2.
A 4 mm capsulorhexis results in longer post-operative ELPo than does a 6 mm capsulorhexis for the type of IOL used 3.
To ensure that an IOL’s position in the bag matches the anticipated formula used to calculate its power, the capsulorhexis should be round, centered and smaller than the IOL optic.
1. Hill WE. Hitting Emmetropia. Chang D. (ed.) In: Mastering Refractive IOLs – The Art and Science. Slack, Incorporated, 2008.
2. Hill WE. Does the Capsulorhexis Affect Refractive Outcomes? Chang D. (ed.) In: Cataract Surgery Today, Bryn Mawr Communications, Wayne, Pennsylvania 2009. p. 78.
3. Cekic, Batman. Ophthalmic Surgery and Lasers, March 1999
Diathlasis Day Care Unit, Thessaloniki, Greece
Femtosecond Laser Phacofragmentation
Liquefy pattern requires I&A only, no phaco power
Chop pattern efficiently fragments the lens for
removal with reduced phaco power and time
Diathlasis Day Care Unit, Thessaloniki, Greece
Incision Configurations Single or Multiplane
Computerized programming of incision patterns
Customizable geometry
Angle
Depth
Width
Diathlasis Day Care Unit, Thessaloniki, Greece
Different operating environment
Laser-generated gas increases the capsular bag volume
The nucleus fragmentation technique is altered
There are laser-included changes within the cortex that make
cortical removal different
Less viscoelastic is required
Hydrodissection may be eliminated
Diathlasis Day Care Unit, Thessaloniki, Greece
New problems
Incomplete capsulorhexis can result in radial extension
Miosis
Capsular block sydrome
Poor incisions
Subconjuctival hemorrage
Diathlasis Day Care Unit, Thessaloniki, Greece
Diathlasis Day Care Unit, Thessaloniki, Greece
Safety of FLACS
Diathlasis Day Care Unit, Thessaloniki, Greece
Who is not a candidate?
Does not dilate past 5,5mm
Retinal and optic nerve disease: h/o AION
Advanced glaucoma w/VF loss
Effects of IOP elevation during docking?
Fuch’s / corneal edema
An advantage with Fuch’s (easier capsulorhexis) reduction in
endothelial cell loss
Diathlasis Day Care Unit, Thessaloniki, Greece
Inability to dock:
Corneal surface irreg, conjuntivochalasis, trabec bleb, unusual orbital
anatomy (small, deep, excess retropulsion)
Agitated patients
Not so good candidates
Diathlasis Day Care Unit, Thessaloniki, Greece
Femtosecond Cataract Innovations
Pediatric cataract surgery
Posterior laser–assisted capsulotomy
Development of new IOL types implanted with a completely new mode of fixation
Statistical analysis between laser assisted and conventional cataract, based on a sample of Diathlasis Day Care Unit.
Diathlasis Day Care Unit, Thessaloniki, Greece
Gender distribution
Age distribution
Prefecture distribution
IOL type distribution
Comparison of post-operative outcome between the two methods
Purpose: To compare the 1 month post-operative SE and UDVA between
Laser Assisted and Conventional Cataract, by Monofocal, Multifocal, TMF
and Toric IOLs.
Setting: Diathlasis Day Care Unit, Thessaloniki, Greece
Are the visual results better than manual surgery?
Statistical analysis between laser assisted and conventional cataract
surgery, based on a sample of Diathlasis Day Care Unit.
Diathlasis Day Care Unit, Thessaloniki, Greece
Laser-assisted Cataract Gender Distribution
TOTAL NUMBER
OF EYES (n) FEMALE MALE
90 50 40
100% 55.56% 44%
56% 44%
Laser-assisted Cataract Gender Distribution
FEMALE
MALE
Diathlasis Day Care Unit, Thessaloniki, Greece
Laser-assisted Cataract Age Distribution
Age = (55.40 ± 11.987) years 17 years < Age range < 87 years
Mode = 50 years
Diathlasis Day Care Unit, Thessaloniki, Greece
Laser-assisted Cataract Prefecture Distribution
Diathlasis Day Care Unit, Thessaloniki, Greece
IOL Type Eyes (n) Eyes (%)
MONOFOCAL 46 51%
MULTIFOCAL 13 14%
TMF 4 4%
TORIC 27 30%
Laser-assisted Cataract IOL Type Distribution
n=90 eyes
Diathlasis Day Care Unit, Thessaloniki, Greece
1 month post-operative SE by IOL type for patients undergoing Laser-assisted cataract surgery
SE monofocal IOL =(-0.604D ± 0.769D) -2.13D< SE post-operative range <0.50D
SE multifocal IOL =(-0.125D ± 0.228D) -0.75D< SE post-operative range <0.00D
SE toric IOL =(-0.452D ± 0.668D) -2.38D< SE post-operative range <0.25D
SE TMF IOL =(-0.188D ± 0.217D) -0.38D< SE post-operative range <0.00D
Diathlasis Day Care Unit, Thessaloniki, Greece
1 month post-operative UDVA by IOL type for patients undergoing Laser-assisted cataract surgery
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparison of 1month post-operative SE between Laser assisted & Conventional Cataract
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparison of 1month post-operative UDVA between Laser assisted & Conventional Cataract
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparison of 1 month post-operative SE between the two methods by Monofocal IOL
SE Laser-assisted=(-0.604D ± 0.769D) -2.125D< SE post-operative range <+0.50D
SE Conventional=(-0.473D ± 0.651D)
-2.125D< SE post operative range <+1.75D
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparison of 1 month post-operative UDVA between Laser Assisted & Conventional Cataract, by Monofocal IOL
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparison of 1 month post-operative SE between the two methods by Multifocal IOL
SE Laser-assisted=(-0.125D ± 0.228D) -0.75D< SE post-operative range <0.00D
SE Conventional=(-0.173D ± 0.40D)
-1.00D< SE post operative range <+0.38D
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparison of 1 month post-operative UDVA between the two methods by Multifocal IOL
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparison of 1 month post-operative SE between the two methods by TMF IOL
SE Laser-assisted=(-0.188D ± 0.217D) -0.375D< SE post-operative range <0.00D
SE Conventional=(-0.50D ± 0.586D)
-1.125D< SE post operative range <+0.00D
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparison of 1 month post-operative UDVA between the two methods by TMF IOL
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparison of 1 month post-operative SE between the two methods by Toric IOL
SE Laser-assisted=(-0.452D ± 0.668D) -0.238D< SE post-operative range <0.25D
SE Conventional=(-0.327D ± 0.673D)
-1.88D< SE post operative range <+0.63D
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparison of 1 month post-operative UDVA between the two methods by Toric IOL
Diathlasis Day Care Unit, Thessaloniki, Greece
Comparing laser-assisted vs. conventional refractive cataract surgery Premium IOLs improve visual and refractive outcomes
This was a retrospective study that compared the visual outcomes of 32 eyes from 32 patients undergoing laser assisted refractive cataract surgery with Alcon LenSx (laser group) vs. 30 eyes from 30 patients undergoing nventional refractive cataract surgery (conventional group), all with implantation of premium IOLs —e.g. Alcon AcrySof IQ Toric IOL (Toric), Alcon ReStor IOL (ReStor), and AMO Tecnis Multifocal IOL (TMF)—by the same surgeon, TJ. The primary outcomes were refractive measures mean spherical equivalent (MSE) and uncorrected logMAR acuity at one month post op.
Factors such as age, sex, axial length, preoperative corneal keratometry, and IOL types
were assessed to ensure similarity between the two groups. Statistical analysis was
performed using the two sample T-test and Mann-U test.
Inclusion criteria were only one eye per subject was eligible, only subjects who received a
premium IOL were included, and their target distance correction had to be plano.
Exclusion criteria were the presence of any macular abnormality, corneal dystrophy or degeneration, pseudoexfoliation, or a history of corneal surgery—LASIK, PRK, CK, or RK/AK.
September 29, 2014 By Loretta T. Ng OD FAAO, Tyrie L. Jenkins MD, Andrew L. Nguyen PhD
Diathlasis Day Care Unit, Thessaloniki, Greece
Diathlasis Day Care Unit, Thessaloniki, Greece
There is no doubt that this technology has added costs and ultimately
it is the patients who will pay for this addition to the procedure.
Who will pay for it?
Diathlasis Day Care Unit, Thessaloniki, Greece
Do We Really Need This?
Femtosecond laser–assisted cataract surgery seems to be a safe,
efficient, and reproducible procedure but further prospective
randomized studies will demonstrate the potential clinical benefits of
this emerging technology
Patients often will not understand what “laser cataract surgery” is and
what benefits it may provide them
Just as FemtoLASIK coexists with mechanical microkeratomes, so does
FLACS coexist with manual surgery
There is place for both
Diathlasis Day Care Unit, Thessaloniki, Greece
FLACS
Is Femto cataract surgery here to stay?
Diathlasis Day Care Unit, Thessaloniki, Greece
Femtosecond Laser Cataract Surgery Is this the future?
Diathlasis Day Care Unit, Thessaloniki, Greece
THANK YOU